1986, 10-07 Permit App: 00013575 Plumbing FixturesPLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Protect #
9
Owner's Name Last First MI
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•
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Project Address (Street e Number}
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City
St to
Subdivision/ Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State ( Zip
Phone
Business Phone
Contractor --
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Address
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City 1 State
Zip
Phone
Conta
License N
1-/4/ i3 t I /4,�,J3
Business Phone
Describe Work
/
BarSlnk(s):
Drinking Fountain(s):
Floor Drain (s):
•
Washing Machine(s): /
Gbh Wshr(s):
Garb Dlsp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal (s):
WtrCloset (s): j
�.J
Lav(s): -
t
Shower(s):
Tub(s):
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): / ( Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System (s), including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16:1-5:
(005 + :
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions y other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT
APPLICATION
DATE